Feeling the responsibility: Exploring the emotional experiences of final-year medical students when carrying out clinical tasks.

PURPOSE: The concept of Entrustable Professional Activities (EPA) is increasingly used to operationalize learning in the clinical workplace, yet little is known about the emotions of learners feeling the responsibility when carrying out professional tasks. METHODS: We explored the emotional experiences of medical students in their final clerkship year when performing clinical tasks. We used an online reflective diary. Text entries were analysed using inductive-deductive content analysis with reference to the EPA framework and the control-value theory of achievement emotions. RESULTS: Students described a wide range of emotions related to carrying out various clinical tasks. They reported positive-activating emotions, ranging from enjoyment to relaxation, and negative-deactivating emotions, ranging from anxiety to boredom. Emotions varied across individual students and were related to the characteristics of a task, an increasing level of autonomy, the students' perceived ability to perform a task and the level of supervision provided. DISCUSSION: Emotions are widely present and impact on the workplace learning of medical students which is related to key elements of the EPA framework. Supervisors play a key role in eliciting positive-activating emotions and the motivation to learn by providing a level of supervision and guidance appropriate to the students' perceived ability to perform the task.

A qualitative study applying Bourdieu's concept of field to uncover social mechanisms underlying major curriculum reform.

PURPOSE: Planning committees play a key role in blueprinting major curriculum reform. In this qualitative study, we apply Bourdieu's sociological concept of field to the perceptions of committee members to identify the social mechanisms operating in major curriculum reform. METHOD: A planning committee with 18 members developed a blueprint for major curriculum reform at the Charité Berlin in its transition from a discipline-based programme to a fully integrated undergraduate medical programme. Interviews with 13 members about their experiences were subjected to inductive-deductive content analysis. RESULTS: Viewed through a Bourdieuan lens, the curriculum committee represents a social field of intense competition and conflicts. Groups of committee members struggled for and with different forms of economic, cultural and social capital to maintain and increase their power and social position in the medical programme. In our case, the major reform was accompanied by loss of power within the teaching department group, while the student group gained power. CONCLUSION: Bourdieu's concept of field reveals that a major curriculum reform is substantially shaped by power struggles over various forms of capital and social positions related to the future curriculum. The findings may serve as a complementary guide for those navigating the complexity of major curriculum reform.

Assessment of Annual Diabetic Eye Examination Using Telemedicine Technology Among Underserved Patients in Primary Care Setting.

CONTEXT: Digital retinal imaging with the application of telemedicine technology shows promising results for screening of diabetic retinopathy in the primary care setting without requiring an ophthalmologist on site. AIMS: We assessed whether the establishment of telemedicine technology was an effective and efficient way to increase completion of annual eye examinations among underserved, low-income (Medicaid) diabetic patients. SETTINGS AND DESIGN: A cross-sectional study in a primary care setting. SUBJECTS AND METHODS: Health care claims data were collected before the establishment of telemedicine technology in 2010 and after its implementation in 2012 for Medicaid patients at East Baltimore Medical Center (EBMC), an urban health center that is part of Johns Hopkins Health System. STATISTICAL ANALYSIS USED: The primary outcome measure was the compliance rate of patients with diabetic eye examinations; calculated as the number of diabetic patients with a completed telemedicine eye examination, divided by the total number of diabetic patients. RESULTS: In 2010, EBMC treated 213 Medicaid diabetic patients and in 2012 treated 228 Medicaid patients. In 2010, 47.89% of patients completed their annual diabetic eye examination while in 2012 it was 78.07% (P < 0.001). After adjustment for age, gender, HgBA1C, disease severity, using resource utilization band score as a proxy, and medication possession ratio; telemedicine technology significantly increased the compliance (odds ratio: 4.98, P < 0.001). CONCLUSIONS: Adherence to annual eye examinations is low in the studied Medicaid diabetic population. Telemedicine technology in a primary care setting can increase compliance with annual eye examinations.

Teaching Integrative Medicine to Residents: A Focus on Populations Rather Than Individual Patients.

INTRODUCTION: Integrative medicine (IM) is by its very definition patient centric: "It reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches." Best methods for teaching IM in residency have not been well described. METHODS: An IM curriculum for preventive medicine (PM) residents was thoughtfully developed and iteratively revised using Kern's six-step approach. The centerpiece of this curriculum was to have learners work collaboratively within teams on projects that would facilitate IM-focused care within primary care practices. Before embarking on specific IM-related projects, residents immersed themselves within the practices to understand the needs of the community. RESULTS: Forty-eight PM residents have participated in the curriculum in the last 3 years, and 27 unique physician preceptors served as mentors for the projects. Both residents and preceptors enjoyed working on the projects, and both groups considered the work to be a valuable educational pursuit. Common IM content areas covered by the projects dealt with interprofessional collaboration, health promotion, and population-based prevention. Although there were challenges associated with implementation of the projects, overcoming these enhanced the PM residents' confidence and ability to serve as agents of change. CONCLUSIONS: An IM curriculum was successfully incorporated into a PM residency program. The focus on serving the community, or a population health approach, may not be the most common approach in IM, but it worked effectively to enhance the IM knowledge and skills of PM residents.

Annual diabetic eye examinations in a managed care Medicaid population.

OBJECTIVES: To assess how well a managed care organization performed annual diabetic eye screening in a Medicaid population, and to identify barriers to completion. STUDY DESIGN: Cross-sectional study. METHODS: Healthcare claims data for all Medicaid patients with diabetes covered by Priority Partners Managed Care Organization in 2010 and 2012 were collected, and the annual rates for diabetic eye exams in those years were reported. Predictors of completion of the diabetic eye exam in primary care clinics in 2010 and 2012 were assessed using a logistic regression model. RESULTS: We identified 8902 Medicaid patients with a diagnosis of diabetes using the Healthcare Effectiveness Data and Information Set codes: 3838 patients in 2010 and 5064 patients in 2012. In 2010 and 2012, 46% and 64% of patients, respectively, had completed their annual diabetic eye exam. The increase in participation in annual eye exams from 2010 to 2012 was statistically significant (P < .001). Among the factors increasing the likelihood of completion of an annual diabetic eye exam among the Medicaid population were access to a nonmydriatic fundoscopic camera in the primary care clinic, compliance with glycated hemoglobin measurement based on the recommended guidelines, incentives offered to primary care offices, and higher resource utilization band score. Financial incentives to patients, however, lowered the completion rate. CONCLUSIONS: Annual diabetic eye exam completion is low among the Medicaid population. Detecting high-risk patients and adjusting for factors that play a role in nonadherence both increase the rate of annual diabetic eye exams among underserved populations such as Medicaid patients.

Role of preventive medicine residencies in medical education: a national survey.

BACKGROUND: In an era of substantial reform to the nation's health system, there has never been a greater need for physicians to understand public health. One way to foster public health in medical education is to utilize the resources within General Preventive Medicine and Public Health (PM) residency programs. Trained in public health and clinical medicine, PM physicians are uniquely positioned to bridge these disciplines. PURPOSE: Little is known about the level of engagement of PM residency programs in medical education. This study explores the current state of their involvement. METHODS: Program directors from all Accreditation Council for Graduate Medical Education-accredited PM residency programs were asked to participate in a survey to assess involvement in medical student and non-PM resident education, including on nine key engagement criteria covering teaching, rotations, career interest groups, and other activities. The study was conducted and data analyzed in 2010. RESULTS: Thirty-five of 38 (92%) programs responded. Seventy-four percent reported that PM faculty taught medical students, and 34% taught at non-PM residency programs. The lowest level of engagement was seen in PM residents teaching non-PM residents (12%). Over half of all programs met four or fewer of the nine criteria. The most common barriers to engagement were lack of funding (53%) and lack of time (50%). CONCLUSIONS: These results suggest that PM residency programs are an underutilized resource in fostering public health in medical education, especially on engagement at the level of graduate medical education. Strategies to improve engagement should consider the nine criteria outlined in this study, as well as common barriers.

Prevention in the United States Affordable Care Act.

The Affordable Care Act (ACA) was signed into law on March 23, 2010 and will fundamentally alter health care in the United States for years to come. The US is currently one of the only industrialized countries without universal health insurance. The new law expands existing public insurance for the poor. It also provides financial credits to low income individuals and some small businesses to purchase health insurance. By government estimates, the law will bring insurance to 30 million people. The law also provides for a significant new investment in prevention and wellness. It appropriates an unprecedented $15 billion in a prevention and public health fund, to be disbursed over 10 years, as well as creates a national prevention council to oversee the government's prevention efforts. This paper discusses 3 major prevention provisions in the legislation: 1) the waiving of cost-sharing for clinical preventive services, 2) new funding for community preventive services, and 3) new funding for workplace wellness programs. The paper examines the scientific evidence behind these provisions as well as provides examples of some model programs. Taken together, these provisions represent a significant advancement for prevention in the US health care system, including a shift towards healthier environments. However, in this turbulent economic and political environment, there is a real threat that much of the law, including the prevention provisions, will not receive adequate funding.

Emergency preparedness: addressing a residency training gap.

As the importance of physician involvement and leadership in crisis preparedness is recognized, the literature suggests that few physicians are adequately trained to practice effectively in a large-scale crisis situation. A logical method for addressing the emergency preparedness training deficiency identified across several medical specialties is to include disaster and emergency preparedness training in residency curricula. In this article, the authors outline the development and implementation of an emergency preparedness curriculum for the Johns Hopkins General Preventive Medicine Residency (JHGPMR) from 2004 to 2006. The curriculum consists of two components. The first was developed for the academic year in the JHGPMR and includes didactic lectures, practical exercises to apply new knowledge, and an opportunity to integrate the knowledge and skills in a real-world exercise. The second, developed for the practicum year of the residency, includes Web-based lectures and online content and culminates in a tabletop preparedness exercise. Topics for both components include weapons of mass destruction, risk communication and personal preparedness, aspects of local emergency response planning, and mental health and psychological aspects of terrorism. On the basis of the emergency preparedness training gap that has been identified in the literature, and the success of the three-year experience in implementing a preparedness training curriculum in the JHGPMR, the authors recommend incorporation of competency-based emergency preparedness training for residencies of all specialties, and offer insights into how the described curriculum could be adapted for use in other residency settings.

Adolescent physical activities as predictors of young adult weight.

OBJECTIVE: To examine the relationship between increased physical activity in adolescence and adult weight status. DESIGN: Cohort study based on data from the National Longitudinal Study of Adolescent Health. SETTING: In-home interviews. PARTICIPANTS: A total of 3345 adolescents in grades 8 to 12 with body mass index (calculated as weight in kilograms divided by height in meters squared) data available at baseline and 5 years later. Main Exposures Days per week of curricular and extracurricular physical activity. MAIN OUTCOME MEASURE: Overweight status (body mass index > or =25) 5 years after baseline. RESULTS: Increasing participation in certain extracurricular physical activities and physical education decreased the likelihood of young adulthood overweight. Regarding extracurricular physical activities, the likelihood of being an overweight adult was reduced most (ie, 48%) by performing certain wheel-related activities (ie, rollerblading, roller skating, skateboarding, or bicycling) more than 4 times per week. Each weekday that adolescents participated in physical education decreased the odds of being an overweight adult by 5%, with participation in all 5 weekdays of physical education decreasing the odds by 28%. In general, physical activity predicted normal-weight maintenance better than weight loss. CONCLUSION: These data underscore the important role that school-based and extracurricular physical activity play in reducing the likelihood of transitioning to overweight as young adults.

Physician counseling to prevent overweight in children and adolescents: American College of Preventive Medicine position statement.

The American College of Preventive Medicine (ACPM) this position statement is intended to guide physicians in counseling children and adolescents to prevent overweight. Rigorous reviews of the published literature have found insufficient evidence to permit the development of formal recommendations by the US Preventive Services Task Force and others. However, numerous public health and physician organizations have developed recommendations on the basis of expert opinion, professional judgment, and the available scientific evidence. This article presents the position of the ACPM in light of these ambiguities. The ACPM will review and modify its recommendations as new scientific evidence emerges.